Communication
A workshop to introduce residents to effective handovers Liam Rourke and Curtiss Boyington Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
SUMMARY Background: Patient safety is associated with the quality of handover, yet many residents train in settings that lack a formal procedure for handover. Thus, they have few opportunities to observe or participate in effective practices. The purpose of our project was to design an educational experience that would introduce residents to the essentials of an effective handover. Context: Through a review of the literature, conversations
with our residents and teaching doctors, and needs analysis survey, we determined that a formal, didactic, large group, face-to-face educational experience focusing on lowerlevel educational objectives would meet the needs of our learners. Innovation: Our curriculum development culminated in a 90–minute, multifaceted workshop comprising a brief introduction to handover, a dramatisation of effective and ineffective
practices, and a role-play activity, followed by a debriefing session. Implications: Objective, constructed response tests, administered before and after the workshop, suggested that the workshop provided residents with the knowledge that a good handover is structured, free of distraction and prioritised. Some of the misconceptions that were apparent at the beginning of the workshop, however, were unchanged by the learning activities.
Many residents train in settings that lack a formal procedure for handover
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102 99
tct_12263.indd 99
3/11/2015 5:28:27 PM
Handover training is a critical component of resident education because of its favourable impact on patient safety
INTRODUCTION
T
he Accreditation Council for Graduate Medical Education (ACGME) argues that handover training is a critical component of resident education because of its favourable impact on patient safety. How the residents might be trained, however, is not yet settled. A systematic review of interventions to improve handover concluded that the literature was sparse, its quality was poor and it results inconclusive.1 The purpose of this report is to describe the development, delivery and evaluation of a workshop to introduce senior residents to quality handover practices. Our report begins with an overview of the model we used to guide curriculum development, and then describes our work in each of its six steps.
Curriculum development model We used Kern, Thomas and Hughes’ model of curriculum development, comprising six steps: (1) problem identification; (2) targeted needs assessment; (3) articulation of educational objectives; (4) selection of instructional strategies; (5) implementation; and (6) maintenance and evaluation.2 These processes are common across instructional design models, but Kern et al.’s formulation is addressed specifically to medical educators. Problem identification The purpose of the first step is to identify a gap between ideal and current practice. Several studies suggest that an ideal handover is standardised, although responsive to context, supported by informatics and conducted in settings free of distraction.3 Unfortunately, several years after prompting from the ACGME, observational studies of handover continue to describe unstructured communication processes, routine distractions and handovers that are characterised as poor by their
participants.4 This gap between current and ideal practice is apparent in reports of handoverrelated medical error.5
identified the following 10 as important and feasible.
Targeted needs assessment A targeted needs assessment determines the extent to which the problem presented in the literature affects a local setting. In conversations with our residents, staff doctors and educational leads in our teaching hospitals, we heard either that no formal handover process was in place or that an existing process was unsatisfactory. Given the limited experience with ideal handover practices, we determined that an introduction to the topic was needed. To augment the information we acquired through the conversations, we administered a needs assessment survey adapted from an existing instrument that had been administered and validated in a previous study.6 Our version consisted of 22 items that asked the residents to indicate the importance and the feasibility of three dimensions of improving handover: (1) the type of intervention (formal training, workplace-based learning or changes to practice); (2) the topics to be included in training (e.g. communication, standardisation, mnemonics); and (3) the types of learning activities (e.g. role-play, formal lectures, group discussions, etc.). Briefly, of 30 possibilities, the respondents
2. Involve participants in problem-solving activities.
1. Use examples of good and bad handover technique.
3. Make the practical value of handover training apparent. 4. Customise training to local needs. 5. Create an environment in which handover mistakes are identified and corrected in a non-judgemental way. 6. Encourage participants to identify obstacles that they might face as they implement handover skills in their daily practice. 7. Introduce a mnemonic that can be used subsequently to structure handover communication. 8. Standardised handover training to ensure uniform content and process. 9. Identify and correct faults in the handover system. 10. Conduct training in an environment that resembles the clinical setting. Based on the responses, we identified formal training as the preferred means of improving handover, and we developed an educational experience built around suggestions 1–7.
100 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102
tct_12263.indd 100
3/11/2015 5:28:28 PM
Educational objectives Given the rudimentary training needs, and based on their responses to the needs assessment, we articulated educational objectives at the lower levels of Bloom’s taxonomy, specifically knowledge and comprehension. The topics that we wanted participants to learn and understand were: using a mnemonic to structure communication during a handover and the keys to an effective handover. We presented the Situation Background Assessment Recommendations Review (SBARR) mnemonic because it is the most common, is currently used by other health professionals in our teaching hospitals and because a systematic review of handover mnemonics provides few reasons to disregard these advantages.7 The keys to effective handover that we emphasised were: (1) conduct handover in an environment with limited interruptions, noise and distractions; (2) standardise the handover communication; and (3) prioritise cases and information. Crossing the topics with the knowledge levels yielded four educational objectives: (1) recall a mnemonic for structuring handover communication; (2) list its constituents; (3) provide an example of relevant information for each letter of the mnemonic; and (4) list three keys to an effective handover. Instructional strategies For participants to achieve these objectives, and in consideration of their responses to the survey, we developed a 90–minute, face-toface workshop that included three learning activities: a short lecture, a video and a role-play. The lecture was approximately 10 minutes in duration; it was supported with slides containing text that underscored key concepts, and its purpose was to present and explain the core concepts of the workshop: namely, that the frequency of handovers has increased as residents’ duty hours have decreased; the quality of patient
safety is tied to the quality of handover; and a manageable set of skills and processes are common to effective handovers. The video was 5 minutes in duration, and it dramatised and juxtaposed handover practices that were effective and ineffective.8 The roleplay activity lasted 30 minutes. It provided an opportunity for participants to practice structured handovers and apply the mnemonic presented in the workshop. Briefly, participants enacted four roles: a presenter transferred the care of patients to a receiver; a distracter taxed the others’ attention; and an evaluator judged the effectiveness of the handover using a validated checklist that we obtained from the literature.9 Implementation Implementing the workshop required a number of personnel, facilities, funds and operations. Personnel included a doctor, who was a medical educator at one of our teaching hospitals, to lead the workshop, three senior residents to distribute materials and assist the groups during the role-play, two administrative staff to book a facility, arrange furniture, and schedule the workshop, and a large room with tables, chairs, and a projector and computer for the slideshow. Operations included the preparation of curricular materials: primarily the slides, the role-play materials, and the evaluative materials. Evaluation We administered tests before and after the workshop to gauge the participants’ learning. The test comprised 13 constructedresponse items corresponding to the three educational objectives, and identical versions of the test were administered before and after the workshop. We found a substantial difference in the means of participants’ pre- and postworkshop scores for each of the educational objectives: (1) identify the constituents of the SBARR
mnemonic (MD = 4.57, effect size d = 1.18); (2) provide an example of relevant information for each letter of the mnemonic (MD = 2.4, d = 1.47); (3) list three key components of an effective handover (MD = 1.03, d = 0.89). Together, there was a substantial difference between pre- and post-workshop scores [MD = 11.00, SD = 1.65, t(48) = 18.63, p < 0.001]. The aggregate effect size was d = 2.87, which is conventionally interpreted as large; however, we did find that some conceptualisations of the handover expressed by some participants prior to the workshop remained vague afterwards. When asked to list the keys of effective handover, for instance, many wrote only ‘communication’, ‘enough time’ or ‘dedicated location’. There was no evidence to indicate that these notions, although not incorrect, were enriched by the fuller conceptions presented in the workshop.
We administered tests before and after the workshop to gauge the participants' learning
Maintenance and enhancement In response to requests and in light of the encouraging evaluation, we will continue to offer this workshop. As we do so, we will enhance each of the aspects described above. Regarding problem identification, we will continue to review the literature for evidence of effective means of preparing residents. A large study published recently argues that formal training is only one component of successful interventions to improve handover; additional components are essential to improve patient safety.10 Regarding the targeted needs assessment, we are currently collecting data to supplement the opinions offered by our residents to our initial survey. The data will come from structured interviews with residents and observations of them engaged in handover while on service in our teaching hospitals. The additional details provided by these studies will help us to refine our educational objectives so that they address empirically determined needs.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102 101
tct_12263.indd 101
3/11/2015 5:28:29 PM
The workshop will be interest to others because it responds to parameters that are commonplace
CONCLUSION Concern about the quality of handover has escalated over the last several years, and medical educators have been directed to include this skill in residents’ training. Several instructional design chronologies have appeared in the literature, but reviewers are not persuaded of their effectiveness or their usefulness for other designers. Here, we described the systematic development of an educational experience to introduce residents to handover. We feel that the workshop will be of interest to others because it responds to parameters that are commonplace: it is approximately 90 minutes in length, it is introductory, it presents a manageable number of key concepts and it provides sufficient detail for replication. Moreover, we have identified some useful tools from the literature, and directed readers to them, including a needs analysis
survey, a tool for evaluating the quality of handover, and a test of participants’ knowledge. REFERENCES 1. Morris G, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ 2011;45:1081–1089. 2. Kern DE, Thomas PA, Hughes MT (eds). Curriculum development for medical education: a six-step approach. Baltimore, MD: JHU Press; 2010. 3. Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, Padmore JS, Karpovich KP. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med 2009;84:1775–1787. 4. Johner A, Merchant S, Aslani N, Planting A, Ball CG, Widder S, Pagliarello G, Parry NG, Klassen D, Hameed SM. Acute general surgery in Canada: a survey of current handover practices. Can J Surg 2013;56:E24–E28. 5. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med 2005;165:2607–2613.
6. Stoyanov S, Boshuizen H, Groene O, van der Klink M, Kicken W, Drachsler H, Barach P. Mapping and assessing clinical handover training interventions. BMJ Qual Saf 2012;21:i50–i57. 7. Reisenberg LA. Systematic review of handoff mnemonics literature. American Journal of Medical Quality 2009;24.3: 196–204. 8. Eskildsen M, Bonsall J, Miller A, Ohuabunwa U, Payne C, Rimler E, Stein J. Handover and care transitions training for internal medicine residents. MedEdPORTAL; 2012. Available at: https:// www.mededportal.org/publication/9101. Accessed on 15 May 2014. 9. Leggio L. A validated tool to evaluate verbal handovers in a clinical setting. MedEdPORTAL; 2013. Available at: http://www. mededportal.org/icollaborative/ resource/836. Accessed on 15 May 2014. 10. Starmer AJ, Sectish TC, Simon DW et al. Rates of Medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA 2013;310:2262–2270.
Corresponding author’s contact details: Dr Curtiss Boyington, Department of Medicine, University of Alberta, Room 0637 1100 Youvill Drive Grey Nuns Hospital, Edmonton, Alberta, Canada. E-mail: [email protected]
Funding: None. Competing interests: None. Acknowledgements: None. Ethical approval: This study has been approved by the University of Alberta Research Ethics Board. doi: 10.1111/tct.12263
102 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102
tct_12263.indd 102
3/11/2015 5:28:29 PM
Copyright of Clinical Teacher is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
A workshop to introduce residents to effective handovers Liam Rourke and Curtiss Boyington Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
SUMMARY Background: Patient safety is associated with the quality of handover, yet many residents train in settings that lack a formal procedure for handover. Thus, they have few opportunities to observe or participate in effective practices. The purpose of our project was to design an educational experience that would introduce residents to the essentials of an effective handover. Context: Through a review of the literature, conversations
with our residents and teaching doctors, and needs analysis survey, we determined that a formal, didactic, large group, face-to-face educational experience focusing on lowerlevel educational objectives would meet the needs of our learners. Innovation: Our curriculum development culminated in a 90–minute, multifaceted workshop comprising a brief introduction to handover, a dramatisation of effective and ineffective
practices, and a role-play activity, followed by a debriefing session. Implications: Objective, constructed response tests, administered before and after the workshop, suggested that the workshop provided residents with the knowledge that a good handover is structured, free of distraction and prioritised. Some of the misconceptions that were apparent at the beginning of the workshop, however, were unchanged by the learning activities.
Many residents train in settings that lack a formal procedure for handover
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102 99
tct_12263.indd 99
3/11/2015 5:28:27 PM
Handover training is a critical component of resident education because of its favourable impact on patient safety
INTRODUCTION
T
he Accreditation Council for Graduate Medical Education (ACGME) argues that handover training is a critical component of resident education because of its favourable impact on patient safety. How the residents might be trained, however, is not yet settled. A systematic review of interventions to improve handover concluded that the literature was sparse, its quality was poor and it results inconclusive.1 The purpose of this report is to describe the development, delivery and evaluation of a workshop to introduce senior residents to quality handover practices. Our report begins with an overview of the model we used to guide curriculum development, and then describes our work in each of its six steps.
Curriculum development model We used Kern, Thomas and Hughes’ model of curriculum development, comprising six steps: (1) problem identification; (2) targeted needs assessment; (3) articulation of educational objectives; (4) selection of instructional strategies; (5) implementation; and (6) maintenance and evaluation.2 These processes are common across instructional design models, but Kern et al.’s formulation is addressed specifically to medical educators. Problem identification The purpose of the first step is to identify a gap between ideal and current practice. Several studies suggest that an ideal handover is standardised, although responsive to context, supported by informatics and conducted in settings free of distraction.3 Unfortunately, several years after prompting from the ACGME, observational studies of handover continue to describe unstructured communication processes, routine distractions and handovers that are characterised as poor by their
participants.4 This gap between current and ideal practice is apparent in reports of handoverrelated medical error.5
identified the following 10 as important and feasible.
Targeted needs assessment A targeted needs assessment determines the extent to which the problem presented in the literature affects a local setting. In conversations with our residents, staff doctors and educational leads in our teaching hospitals, we heard either that no formal handover process was in place or that an existing process was unsatisfactory. Given the limited experience with ideal handover practices, we determined that an introduction to the topic was needed. To augment the information we acquired through the conversations, we administered a needs assessment survey adapted from an existing instrument that had been administered and validated in a previous study.6 Our version consisted of 22 items that asked the residents to indicate the importance and the feasibility of three dimensions of improving handover: (1) the type of intervention (formal training, workplace-based learning or changes to practice); (2) the topics to be included in training (e.g. communication, standardisation, mnemonics); and (3) the types of learning activities (e.g. role-play, formal lectures, group discussions, etc.). Briefly, of 30 possibilities, the respondents
2. Involve participants in problem-solving activities.
1. Use examples of good and bad handover technique.
3. Make the practical value of handover training apparent. 4. Customise training to local needs. 5. Create an environment in which handover mistakes are identified and corrected in a non-judgemental way. 6. Encourage participants to identify obstacles that they might face as they implement handover skills in their daily practice. 7. Introduce a mnemonic that can be used subsequently to structure handover communication. 8. Standardised handover training to ensure uniform content and process. 9. Identify and correct faults in the handover system. 10. Conduct training in an environment that resembles the clinical setting. Based on the responses, we identified formal training as the preferred means of improving handover, and we developed an educational experience built around suggestions 1–7.
100 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102
tct_12263.indd 100
3/11/2015 5:28:28 PM
Educational objectives Given the rudimentary training needs, and based on their responses to the needs assessment, we articulated educational objectives at the lower levels of Bloom’s taxonomy, specifically knowledge and comprehension. The topics that we wanted participants to learn and understand were: using a mnemonic to structure communication during a handover and the keys to an effective handover. We presented the Situation Background Assessment Recommendations Review (SBARR) mnemonic because it is the most common, is currently used by other health professionals in our teaching hospitals and because a systematic review of handover mnemonics provides few reasons to disregard these advantages.7 The keys to effective handover that we emphasised were: (1) conduct handover in an environment with limited interruptions, noise and distractions; (2) standardise the handover communication; and (3) prioritise cases and information. Crossing the topics with the knowledge levels yielded four educational objectives: (1) recall a mnemonic for structuring handover communication; (2) list its constituents; (3) provide an example of relevant information for each letter of the mnemonic; and (4) list three keys to an effective handover. Instructional strategies For participants to achieve these objectives, and in consideration of their responses to the survey, we developed a 90–minute, face-toface workshop that included three learning activities: a short lecture, a video and a role-play. The lecture was approximately 10 minutes in duration; it was supported with slides containing text that underscored key concepts, and its purpose was to present and explain the core concepts of the workshop: namely, that the frequency of handovers has increased as residents’ duty hours have decreased; the quality of patient
safety is tied to the quality of handover; and a manageable set of skills and processes are common to effective handovers. The video was 5 minutes in duration, and it dramatised and juxtaposed handover practices that were effective and ineffective.8 The roleplay activity lasted 30 minutes. It provided an opportunity for participants to practice structured handovers and apply the mnemonic presented in the workshop. Briefly, participants enacted four roles: a presenter transferred the care of patients to a receiver; a distracter taxed the others’ attention; and an evaluator judged the effectiveness of the handover using a validated checklist that we obtained from the literature.9 Implementation Implementing the workshop required a number of personnel, facilities, funds and operations. Personnel included a doctor, who was a medical educator at one of our teaching hospitals, to lead the workshop, three senior residents to distribute materials and assist the groups during the role-play, two administrative staff to book a facility, arrange furniture, and schedule the workshop, and a large room with tables, chairs, and a projector and computer for the slideshow. Operations included the preparation of curricular materials: primarily the slides, the role-play materials, and the evaluative materials. Evaluation We administered tests before and after the workshop to gauge the participants’ learning. The test comprised 13 constructedresponse items corresponding to the three educational objectives, and identical versions of the test were administered before and after the workshop. We found a substantial difference in the means of participants’ pre- and postworkshop scores for each of the educational objectives: (1) identify the constituents of the SBARR
mnemonic (MD = 4.57, effect size d = 1.18); (2) provide an example of relevant information for each letter of the mnemonic (MD = 2.4, d = 1.47); (3) list three key components of an effective handover (MD = 1.03, d = 0.89). Together, there was a substantial difference between pre- and post-workshop scores [MD = 11.00, SD = 1.65, t(48) = 18.63, p < 0.001]. The aggregate effect size was d = 2.87, which is conventionally interpreted as large; however, we did find that some conceptualisations of the handover expressed by some participants prior to the workshop remained vague afterwards. When asked to list the keys of effective handover, for instance, many wrote only ‘communication’, ‘enough time’ or ‘dedicated location’. There was no evidence to indicate that these notions, although not incorrect, were enriched by the fuller conceptions presented in the workshop.
We administered tests before and after the workshop to gauge the participants' learning
Maintenance and enhancement In response to requests and in light of the encouraging evaluation, we will continue to offer this workshop. As we do so, we will enhance each of the aspects described above. Regarding problem identification, we will continue to review the literature for evidence of effective means of preparing residents. A large study published recently argues that formal training is only one component of successful interventions to improve handover; additional components are essential to improve patient safety.10 Regarding the targeted needs assessment, we are currently collecting data to supplement the opinions offered by our residents to our initial survey. The data will come from structured interviews with residents and observations of them engaged in handover while on service in our teaching hospitals. The additional details provided by these studies will help us to refine our educational objectives so that they address empirically determined needs.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102 101
tct_12263.indd 101
3/11/2015 5:28:29 PM
The workshop will be interest to others because it responds to parameters that are commonplace
CONCLUSION Concern about the quality of handover has escalated over the last several years, and medical educators have been directed to include this skill in residents’ training. Several instructional design chronologies have appeared in the literature, but reviewers are not persuaded of their effectiveness or their usefulness for other designers. Here, we described the systematic development of an educational experience to introduce residents to handover. We feel that the workshop will be of interest to others because it responds to parameters that are commonplace: it is approximately 90 minutes in length, it is introductory, it presents a manageable number of key concepts and it provides sufficient detail for replication. Moreover, we have identified some useful tools from the literature, and directed readers to them, including a needs analysis
survey, a tool for evaluating the quality of handover, and a test of participants’ knowledge. REFERENCES 1. Morris G, Findley R. Educational interventions to improve handover in health care: a systematic review. Med Educ 2011;45:1081–1089. 2. Kern DE, Thomas PA, Hughes MT (eds). Curriculum development for medical education: a six-step approach. Baltimore, MD: JHU Press; 2010. 3. Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, Padmore JS, Karpovich KP. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med 2009;84:1775–1787. 4. Johner A, Merchant S, Aslani N, Planting A, Ball CG, Widder S, Pagliarello G, Parry NG, Klassen D, Hameed SM. Acute general surgery in Canada: a survey of current handover practices. Can J Surg 2013;56:E24–E28. 5. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med 2005;165:2607–2613.
6. Stoyanov S, Boshuizen H, Groene O, van der Klink M, Kicken W, Drachsler H, Barach P. Mapping and assessing clinical handover training interventions. BMJ Qual Saf 2012;21:i50–i57. 7. Reisenberg LA. Systematic review of handoff mnemonics literature. American Journal of Medical Quality 2009;24.3: 196–204. 8. Eskildsen M, Bonsall J, Miller A, Ohuabunwa U, Payne C, Rimler E, Stein J. Handover and care transitions training for internal medicine residents. MedEdPORTAL; 2012. Available at: https:// www.mededportal.org/publication/9101. Accessed on 15 May 2014. 9. Leggio L. A validated tool to evaluate verbal handovers in a clinical setting. MedEdPORTAL; 2013. Available at: http://www. mededportal.org/icollaborative/ resource/836. Accessed on 15 May 2014. 10. Starmer AJ, Sectish TC, Simon DW et al. Rates of Medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA 2013;310:2262–2270.
Corresponding author’s contact details: Dr Curtiss Boyington, Department of Medicine, University of Alberta, Room 0637 1100 Youvill Drive Grey Nuns Hospital, Edmonton, Alberta, Canada. E-mail: [email protected]
Funding: None. Competing interests: None. Acknowledgements: None. Ethical approval: This study has been approved by the University of Alberta Research Ethics Board. doi: 10.1111/tct.12263
102 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 99–102
tct_12263.indd 102
3/11/2015 5:28:29 PM
Copyright of Clinical Teacher is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
